Nursing Home Employee
Health Screening Checklist

Complete this checklist daily before starting your shift to ensure the safety and health of our residents and staff. Report any "yes" responses to your supervisor immediately for further instructions.

Personal Information

Name		Department
Date		Time

Health Screening Questions

Please answer the following questions regarding your current health status.

Are you experiencing any of the following symptoms? (Check all that apply)

• Cough

• Shortness of breath or difficulty breathing

• Fatigue

• Muscle or body aches

• Headache

• New loss of taste or smell

• Sore throat

• Congestion or runny nose

• Nausea or vomiting

• Diarrhea

	Yes	No
Do you have a fever (temperature over 100.4°F/38°C) without having taken any fever-reducing medications?
In the past 14 days, have you been in close contact with anyone who has been diagnosed with COVID-19 or has coronavirus-type symptoms?
Have you tested positive for COVID-19 in the past 10 days?
Have you received any COVID-19 vaccine doses in the past 14 days?
Have you traveled internationally or to a domestic hot spot for COVID-19 in the past 14 days?

Declaration

I declare that the information provided above is accurate to the best of my knowledge, and I understand that providing false information can result in consequences that may include disciplinary action up to and including termination of employment.

Employee

[Name]

[Date]

Supervisor

[Name]

[Date]

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